MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE
Hospital Information
| Facility Name | MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE |
|---|---|
| Address | 509 BILTMORE AVE Asheville, NC 28801 |
| County | BUNCOMBE |
| Hospital Type | Acute Care Hospitals |
| Ownership | Voluntary non-profit - Private |
| Emergency Services | Yes |
| Phone | (828) 213-1111 |
Quality Measures & Clinical Outcomes
Other Measures
| Measure | Score | vs. National |
|---|---|---|
| — | — | |
| — | — | |
| Emergency department volume | very high | — |
| Global Malnutrition Composite Score 5 | Not Available | — |
| Global Malnutrition Composite Score: Malnutrition Diagnosis Documented 5 | Not Available | — |
| Global Malnutrition Composite Score: Malnutrition Risk Screening 5 | Not Available | — |
| Global Malnutrition Composite Score: Nutrition Assessment 5 | Not Available | — |
| Global Malnutrition Composite Score: Nutritional Care Plan 5 | Not Available | — |
| Hospital Harm - Severe Hyperglycemia Based on 62,351 patients | 7 | — |
| Hospital Harm - Severe Hypoglycemia Based on 9,550 patients | 2 | — |
| Hospital Harm - Opioid Related Adverse Events Based on 24,968 patients | 1 | — |
| Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate Based on 4,885 patients | 3.7 | No Different Than the National Rate |
| Safe Use of Opioids - Concurrent Prescribing Based on 12,062 patients | 18 | — |
| Severe Sepsis 3-Hour Bundle Based on 154 patients 2 | 74 | — |
| Severe Sepsis 6-Hour Bundle Based on 77 patients 2 | 88 | — |
Complications
| Measure | Score | vs. National |
|---|---|---|
| Rate of complications for hip/knee replacement patients Based on 371 patients | 3.2 | No Different Than the National Rate |
Healthcare-Associated Infections
| Measure | Score | vs. National |
|---|---|---|
| Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit | 0.410 | No Different than National Benchmark |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit | 1.014 | No Different than National Benchmark |
| Central Line Associated Bloodstream Infection: Number of Device Days | 25515 | No Different than National Benchmark |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases | 28.706 | No Different than National Benchmark |
| Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases | 19 | No Different than National Benchmark |
| Central Line Associated Bloodstream Infection (ICU + select Wards) | 0.662 | No Different than National Benchmark |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit | 0.141 | Better than the National Benchmark |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit | 0.466 | Better than the National Benchmark |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days | 24738 | Better than the National Benchmark |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases | 40.986 | Better than the National Benchmark |
| Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases | 11 | Better than the National Benchmark |
| Catheter Associated Urinary Tract Infections (ICU + select Wards) | 0.268 | Better than the National Benchmark |
| SSI - Colon Surgery: Lower Confidence Limit | 0.572 | No Different than National Benchmark |
| SSI - Colon Surgery: Upper Confidence Limit | 1.716 | No Different than National Benchmark |
| SSI - Colon Surgery: Number of Procedures | 488 | No Different than National Benchmark |
| SSI - Colon Surgery: Predicted Cases | 12.631 | No Different than National Benchmark |
| SSI - Colon Surgery: Observed Cases | 13 | No Different than National Benchmark |
| SSI - Colon Surgery | 1.029 | No Different than National Benchmark |
| SSI - Abdominal Hysterectomy: Lower Confidence Limit | 0.686 | No Different than National Benchmark |
| SSI - Abdominal Hysterectomy: Upper Confidence Limit | 3.518 | No Different than National Benchmark |
| SSI - Abdominal Hysterectomy: Number of Procedures | 387 | No Different than National Benchmark |
| SSI - Abdominal Hysterectomy: Predicted Cases | 3.547 | No Different than National Benchmark |
| SSI - Abdominal Hysterectomy: Observed Cases | 6 | No Different than National Benchmark |
| SSI - Abdominal Hysterectomy | 1.692 | No Different than National Benchmark |
| MRSA Bacteremia: Lower Confidence Limit | 0.345 | No Different than National Benchmark |
| MRSA Bacteremia: Upper Confidence Limit | 1.034 | No Different than National Benchmark |
| MRSA Bacteremia: Patient Days | 250431 | No Different than National Benchmark |
| MRSA Bacteremia: Predicted Cases | 20.954 | No Different than National Benchmark |
| MRSA Bacteremia: Observed Cases | 13 | No Different than National Benchmark |
| MRSA Bacteremia | 0.620 | No Different than National Benchmark |
| Clostridium Difficile (C.Diff): Lower Confidence Limit | 0.183 | Better than the National Benchmark |
| Clostridium Difficile (C.Diff): Upper Confidence Limit | 0.335 | Better than the National Benchmark |
| Clostridium Difficile (C.Diff): Patient Days | 228381 | Better than the National Benchmark |
| Clostridium Difficile (C.Diff): Predicted Cases | 167.727 | Better than the National Benchmark |
| Clostridium Difficile (C.Diff): Observed Cases | 42 | Better than the National Benchmark |
| Clostridium Difficile (C.Diff) | 0.250 | Better than the National Benchmark |
Immunization
| Measure | Score | vs. National |
|---|---|---|
| Healthcare workers given influenza vaccination Based on 6,971 patients | 59 | — |
Mortality
| Measure | Score | vs. National |
|---|---|---|
| Death rate for heart attack patients Based on 750 patients | 10.9 | No Different Than the National Rate |
| Death rate for CABG surgery patients Based on 444 patients | 2.5 | No Different Than the National Rate |
| Death rate for COPD patients Based on 217 patients | 8 | No Different Than the National Rate |
| Death rate for heart failure patients Based on 1,047 patients | 11.5 | No Different Than the National Rate |
| Death rate for pneumonia patients Based on 967 patients | 15.3 | No Different Than the National Rate |
| Death rate for stroke patients Based on 770 patients | 13.5 | No Different Than the National Rate |
Outpatient Procedures
| Measure | Score | vs. National |
|---|---|---|
| Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better Based on 450 patients | 186 | — |
| Average (median) time patients spent in the emergency department before leaving from the visit A lower number of minutes is better Based on 425 patients | 183 | — |
| Average (median) time patients spent in the emergency department before leaving from the visit- Psychiatric/Mental Health Patients. A lower number of minutes is better Based on 24 patients | 375 | — |
| Average (median) time transfer patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 1 | Not Available | — |
| Left before being seen Based on 98,513 patients | 0 | — |
| Head CT results 1 | Not Available | — |
| Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Based on 56 patients | 95 | — |
| Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery 5 | Not Available | — |
| ST-Segment Elevation Myocardial Infarction (STEMI) Based on 60 patients | 62 | — |
Patient Safety
| Measure | Score | vs. National |
|---|---|---|
| Pressure ulcer rate Based on 15,903 patients | 0.05 | Better Than the National Rate |
| Death rate among surgical inpatients with serious treatable complications Based on 326 patients | 175.59 | No Different Than the National Rate |
| Iatrogenic pneumothorax rate Based on 18,397 patients | 0.23 | No Different Than the National Rate |
| In-hospital fall-associated fracture rate Based on 18,901 patients | 0.22 | No Different Than the National Rate |
| Postoperative hemorrhage or hematoma rate Based on 6,201 patients | 2.17 | No Different Than the National Rate |
| Postoperative acute kidney injury requiring dialysis rate Based on 2,684 patients | 1.14 | No Different Than the National Rate |
| Postoperative respiratory failure rate Based on 2,744 patients | 10.74 | No Different Than the National Rate |
| Perioperative pulmonary embolism or deep vein thrombosis rate Based on 6,248 patients | 2.00 | Better Than the National Rate |
| Postoperative sepsis rate Based on 2,669 patients | 3.28 | No Different Than the National Rate |
| Postoperative wound dehiscence rate Based on 1,211 patients | 1.47 | No Different Than the National Rate |
| Abdominopelvic accidental puncture or laceration rate Based on 3,901 patients | 0.50 | No Different Than the National Rate |
| CMS Medicare PSI 90: Patient safety and adverse events composite | 0.68 | Better Than the National Value |
Sepsis Care
| Measure | Score | vs. National |
|---|---|---|
| Appropriate care for severe sepsis and septic shock Based on 154 patients 2 | 62 | — |
| Septic Shock 3-Hour Bundle Based on 36 patients 2 | 83 | — |
| Septic Shock 6-Hour Bundle Based on 25 patients 2 | 88 | — |
Stroke Care
| Measure | Score | vs. National |
|---|---|---|
| Discharged on Antithrombotic Therapy 5 | Not Available | — |
| Anticoagulation Therapy for Atrial Fibrillation/Flutter 5 | Not Available | — |
| Antithrombotic Therapy by End of Hospital Day 2 5 | Not Available | — |
Venous Thromboembolism
| Measure | Score | vs. National |
|---|---|---|
| Venous Thromboembolism Prophylaxis 5 | Not Available | — |
| Intensive Care Unit Venous Thromboembolism Prophylaxis 5 | Not Available | — |
Patient Experience (HCAHPS Survey)
Based on 594 completed surveys. Response rate: 20%.
Patients who reported that their nurses "Always" communicated well
Patients who reported that their nurses "Sometimes" or "Never" communicated well
Patients who reported that their nurses "Usually" communicated well
Nurse communication - linear mean score
Nurse communication - star rating
Patients who reported that their nurses "Always" treated them with courtesy and respect
Patients who reported that their nurses "Sometimes" or "Never" treated them with courtesy and respect
Patients who reported that their nurses "Usually" treated them with courtesy and respect
Patients who reported that their nurses "Always" listened carefully to them
Patients who reported that their nurses "Sometimes" or "Never" listened carefully to them
Patients who reported that their nurses "Usually" listened carefully to them
Patients who reported that their nurses "Always" explained things in a way they could understand
Patients who reported that their nurses "Sometimes" or "Never" explained things in a way they could understand
Patients who reported that their nurses "Usually" explained things in a way they could understand
Patients who reported that their doctors "Always" communicated well
Patients who reported that their doctors "Sometimes" or "Never" communicated well
Patients who reported that their doctors "Usually" communicated well
Doctor communication - linear mean score
Doctor communication - star rating
Patients who reported that their doctors "Always" treated them with courtesy and respect
Patients who reported that their doctors "Sometimes" or "Never" treated them with courtesy and respect
Patients who reported that their doctors "Usually" treated them with courtesy and respect
Patients who reported that their doctors "Always" listened carefully to them
Patients who reported that their doctors "Sometimes" or "Never" listened carefully to them
Patients who reported that their doctors "Usually" listened carefully to them
Patients who reported that their doctors "Always" explained things in a way they could understand
Patients who reported that their doctors "Sometimes" or "Never" explained things in a way they could understand
Patients who reported that their doctors "Usually" explained things in a way they could understand
Patients who reported that staff "Always" explained about medicines before giving it to them
Patients who reported that staff "Sometimes" or "Never" explained about medicines before giving it to them
Patients who reported that staff "Usually" explained about medicines before giving it to them
Communication about medicines - linear mean score
Communication about medicines - star rating
Patients who reported that when receiving new medication the staff "Always" communicated what the medication was for
Patients who reported that when receiving new medication the staff "Sometimes" or "Never" communicated what the medication was for
Patients who reported that when receiving new medication the staff "Usually" communicated what the medication was for.
Patients who reported that when receiving new medication the staff "Always" discussed possible side effects
Patients who reported that when receiving new medication the staff "Sometimes" or "Never" discussed possible side effects
Patients who reported that when receiving new medication the staff "Usually" discussed possible side effects
Patients who reported that NO, they were not given information about what to do during their recovery at home
Patients who reported that YES, they were given information about what to do during their recovery at home
Discharge information - linear mean score
Discharge information - star rating
Patients who reported that NO, they did not discuss whether they would need help after discharge
Patients who reported that YES, they did discuss whether they would need help after discharge
Patients who reported that NO, they did not receive written information about possible symptoms to look out for after discharge
Patients who reported that YES, they did receive written information about possible symptoms to look out for after discharge
Patients who reported that their room and bathroom were "Always" clean
Patients who reported that their room and bathroom were "Sometimes" or "Never" clean
Patients who reported that their room and bathroom were "Usually" clean
Cleanliness - linear mean score
Cleanliness - star rating
Patients who reported that the area around their room was "Always" quiet at night
Patients who reported that the area around their room was "Sometimes" or "Never" quiet at night
Patients who reported that the area around their room was "Usually" quiet at night
Quietness - linear mean score
Quietness - star rating
Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest)
Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest)
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)
Overall hospital rating - linear mean score
Overall hospital rating - star rating
Patients who reported NO, they would probably not or definitely not recommend the hospital
Patients who reported YES, they would definitely recommend the hospital
Patients who reported YES, they would probably recommend the hospital
Recommend hospital - linear mean score
Recommend hospital - star rating
Summary star rating
Quick Facts
- Type Acute Care Hospitals
- Ownership Voluntary non-profit - Private
- Rating 4/5
- Emergency Yes
- Measures 88 recorded
Data Source
Hospital data from CMS Hospital Compare. Quality measures and patient experience surveys are updated periodically by the Centers for Medicare & Medicaid Services.
About MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE
MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE is a acute care hospitals located in Asheville, North Carolina. The facility is voluntary non-profit - private owned and provides emergency services. It has an overall quality rating of 4 out of 5 stars from CMS. This hospital has 88 quality measures on record, covering areas such as mortality, readmission rates, complications, and patient safety. Patient experience is measured through the HCAHPS survey, with 594 surveys available for review.